Life and death in the ICU

ICU doctor and Head of BC Transplant Dr. Greg Grant shakes the hand of former patient Julian Recto inside St. Paul’s Hospital in Vancouver.Photo by
Arlen Redekop

In the dying light of a May evening, Julian Recto had his last rites.

The 22-year-old, mere weeks away from graduation, lay in an intensive-care bed at St. Paul’s Hospital, hooked up to a ventilator.

As the priest anointed Julian’s palms and forehead with oil and delivered the sacrament, Julian’s mom Giselda, brother Jordan, and other loved-ones laid their hands on him and prayed.

“I was praying for him to survive,” recalls Giselda.

She couldn’t hold back the tears running down her cheeks, but fought to keep it together. “Even though Julian was sedated, he can still hear. I didn’t want him to hear me crying.”

Traditionally called the last rites, the sacrament is meant to comfort and strengthen a sick person’s soul to face death without fear. In recent practice, it also serves as a prayer for healing for the critically ill.

It was only nine days before when a healthy Julian watched a Whitecaps game at B.C. Place, a birthday present for him and his twin, Jordan.

Oddly, Jordan was sick at the time, hospitalized with pneumonia at Richmond Hospital.

The day after the soccer game, Julian started feeling ill. He had a sore throat, cough, and fever. On the day Jordan was discharged from hospital, Julian went to see a doctor who prescribed him antibiotics to treat bronchitis.

But, unlike his brother, Julian didn’t get better.

He knew something was wrong, that it was no ordinary flu. On May 11, wracked with a 40 C fever, he told his mom he wanted to go to emergency. His last lucid memory was wondering if he should wear the crucifix he normally wears around his neck — a reminder of a vow he made to be true to himself. He was admitted to Richmond Hospital with pneumonia.

The next day, on Mother’s Day, Julian deteriorated rapidly. Restless and delirious, he thought he was in a video game and kept on trying to claw his IV tube out. He was transferred to ICU.

Doctors diagnosed Julian with Acute Respiratory Distress Syndrome, a life-threatening lung condition that causes fluid to build up in the lungs’ air sacs, preventing the flow of oxygen into the lungs and blood stream, possibly leading to lung damage, multi-organ failure, and death.

By this point, Julian’s lungs had stopped working. His kidneys had begun shutting down. The ventilator alone wasn’t much help; Julian needed an extracorporeal membrane oxygenation machine, or ECMO, a machine used for years in cardiac surgeries, but only used to treat respiratory conditions recently.

Richmond Hospital didn’t have one, but St. Paul’s Hospital did. Julian was taken to ICU in an ambulance. The procedure was done bedside. A tube called venous cannula was placed in a large vein on the right side of Julian’s neck, connected to the ECMO. The machine began pumping his blood out, removing carbon dioxide and adding oxygen, then returning the freshly oxygenated blood to his body — essentially, doing the work of his lungs.

In the gazebo room — a comfortable haven down the hall from the hubbub of ICU reserved for conversations such as this — hospital staff told the Rectos about the precariousness of Julian’s condition.

He was the sickest person in hospital, they said. He could die.

A care-home nurse, Giselda braced for the worst. A devout Catholic, she asked St. Paul’s pastoral care team to find a priest. The anointment was held in a private room, window overlooking Davie Street and the darkening sky.

It lasted less than 10 minutes — Julian urgently needed to be on dialysis. Then it was a waiting game.

“ECMO is the most aggressive you can get with lung injury treatment,” said Dr. Demetrios Sirounis, one of Julian’s ICU doctors.

But ECMO does not offer a cure. Doctors still have to treat the underlying disease, and the body still has to do the work and heal.

For all its wonders, all the ECMO does is buy time.

***

In a way, buying time is what intensive care is about.

Intensive care may have little of the frenetic activity of the ER or the glamour of surgery, but at St. Paul’s, the ICU treats the sickest of the sick in B.C., with patients regularly flown in from other parts of the province and the Yukon.

The average duration of stay at the 15-bed critical care unit is five days. The first 24 to 48 hours are the most critical.

The mortality rate is 20 per cent, meaning one in five patients die in ICU. Out of the 80 per cent that move on to wards in other parts of the hosptial, another 10 per cent will die.

“But the reality is, without the ICU, 100 per cent of them would die,” said Dr. Najib Ayas, head of St. Paul’s critical care division.

The intensive care unit, now an integral part of modern-day hospitals, was born in the era of polio epidemics which left patients needing intensive respiratory treatment.

St. Paul’s ICU has two attending physicians on duty during the day, and one-on-one nursing care 24/7. It also has a small army of staff: a pharmacist, respiratory therapists, physiotherapists, occupational therapists, social workers.

It may require lightning-fast interventions — sometimes without knowing what the illness is — before settling into a quiet period of monitoring, observing, watching, and waiting.

“The problem with ICU is you have to diagnose and treat at the same time,” said Ayas. “If you wait, the person dies. You have to make decisions right away to stabilize the patient, figure out what’s going on, and piece the puzzle together.”

On a recent Thursday morning, two attending physicians made the rounds, followed by a multi-disciplinary team.

Their patients included an elderly woman with transverse myelitis, an inflammation of the spinal cord caused by the runaway production of antibodies, and a white-haired frail man brought in after a sudden heart attack.

Dr. Sirounis said intensive care is zero to 100 miles an hour in a heartbeat.

“It’s instant intimacy,” he said. “You’re involved in the biggest decision they will be making — to live or die.”

***

Like many people with loved-ones in intensive care, the Rectos life fell into a pattern.

They alternated between Julian’s bedside, the windowless ICU waiting room, the cafeteria and a small chapel.

Giselda took time off from her job. At night in bed, she tossed and turned. “Your mind is here [in hospital.] My cellphone and home phone were always beside me just in case.”

“You gotta fight through this,” he would tell him. “You’re my twin brother. You’re my other half. I can’t imagine living life without you.”

He reminded Julian of upcoming events they had been looking forward to: Their graduation ceremony at the University of B.C. was less than two weeks away, then their mom’s birthday.

“There were still lots of things we needed to do and experience,” said Jordan.

Slowly, Julian battled back.

Little can be done to cure a viral infection except let it run its course. Doctors bombarded Julian with antibiotics to fight symptoms and bolster his immune system.

Julian remembers little of this. Jordan had told him about his ordeal five times, but it still feels surreal, said Julian, like something that happened to someone else.

“I didn’t know I almost died,” he said. “That came later. I just knew I was really sick.”

Julian spent six days on the ECMO until his lungs got better.

On May 18, he woke up. On May 31, the ventilator came off. Julian was taken to a ward the next day.

There were big bumps on the way to recovery, including a sudden bowel perforation that required emergency surgery.

The reality is life-saving procedures come with a price: ECMO machines carry the risk of stroke or infection; ECMO patients need to be on blood thinners, which increase the risk of internal bleeding; antibiotics exact a toll on the kidney and liver.

The tracheotomy damaged Julian’s vocal cords. Doctors said it might take him nine months to speak; it took Julian two weeks.

It is taking longer for his muscles, which had atrophied from disuse. Even though he began physiotherapy in ICU, he still needs a walker and wheelchair to get around. He had missed his convocation, but will attend the one in November. His goal: To walk across the stage on his own two feet.

Sometimes Giselda wonders whether the same bug that hit Jordan was the same one that nearly killed Julian, but there are no definitive answers.

One thing the family knows: “If this happened five years ago, Julian wouldn’t have had a chance,” said Jordan.

“Without ECMO, he would have died,” said Sirounis, who is studying whether earlier use of ECMO in lung-injured patients improves outcomes.

Ten to 20 years ago, death from the influenza virus was not uncommon. “In this day and age, that should never happen.”

More than three months after he was wheeled out of ICU, Julian, now 60 pounds lighter, returned to ICU for the first time to thank the doctors and nurses who saved his life.

Dr. Greg Grant, another of his physicians, shook his hand and checked out the scar from his tracheotomy. “That healed great.”

I shudder to think how much taxpayers’ money is being spent to defend Premier John Horgan and ...

Vancouver Flyers

Comments

We encourage all readers to share their views on our articles and blog posts. We are committed to maintaining a lively but civil forum for discussion, so we ask you to avoid personal attacks, and please keep your comments relevant and respectful. If you encounter a comment that is abusive, click the "X" in the upper right corner of the comment box to report spam or abuse. We are using Facebook commenting. Visit our FAQ page for more information.

Almost Done!

Postmedia wants to improve your reading experience as well as share the best deals and promotions from our advertisers with you. The information below will be used to optimize the content and make ads across the network more relevant to you. You can always change the information you share with us by editing your profile.

By clicking "Create Account", I hearby grant permission to Postmedia to use my account information to create my account.

I also accept and agree to be bound by Postmedia's Terms and Conditions with respect to my use of the Site and I have read and understand Postmedia's Privacy Statement. I consent to the collection, use, maintenance, and disclosure of my information in accordance with the Postmedia's Privacy Policy.

Postmedia wants to improve your reading experience as well as share the best deals and promotions from our advertisers with you. The information below will be used to optimize the content and make ads across the network more relevant to you. You can always change the information you share with us by editing your profile.

By clicking "Create Account", I hearby grant permission to Postmedia to use my account information to create my account.

I also accept and agree to be bound by Postmedia's Terms and Conditions with respect to my use of the Site and I have read and understand Postmedia's Privacy Statement. I consent to the collection, use, maintenance, and disclosure of my information in accordance with the Postmedia's Privacy Policy.